Common Valvular Heart Disease Flashcards
What are the locations of each of the main valves in the heart?
Mitral - LA -> LV
Aortic - LV -> Aorta
Tricuspid - RA -> Rv
Pulmonary RV -> Lung
What are the causes and what will you find on history/examination of Mitral regurgitation?
Causes: Prolapsing mitral valve Papillary muscle rupture post MI Rheumatic Fever Connective tissue disorders Cardiomyopathy
Symptoms:
Asymptomatic
Regurgitation LVH Left heart failure
Risk Factors:
Prolapsing mitral valve
Differentials: Left Heart Failure Aortic Valve Disease Papillary muscle rupture post MI Rheumatic Fever Connective tissue disorders Cardiomyopathy
Examination:
Chest:
Pan-Systolic murmur that radiates to Axilla
One constant sound with no gap between S1/2
“Burrrrr”
Displaced apex best - volume overload
Palpable thrill
What are the causes and what will you find on history/examination of Mitral regurgitation?
Causes: Prolapsing mitral valve Papillary muscle rupture post MI Rheumatic Fever Connective tissue disorders Cardiomyopathy
Symptoms:
Asymptomatic
Regurgitation LVH Left heart failure
Risk Factors:
Prolapsing mitral valve
Differentials: Left Heart Failure Aortic Valve Disease Papillary muscle rupture post MI Rheumatic Fever Connective tissue disorders Cardiomyopathy
Examination:
Chest:
Pan-Systolic murmur that radiates to Axilla
One constant sound with no gap between S1/2
“Burrrrr”
Displaced apex best - volume overload
Palpable thrill
What are the causes and what will you find on history/examination of Mitral stenosis?
Causes:
Rheumatic Fever
Old Age – Calcification
Symptoms:
Left Atrial Dilation Pulmonary Congestion Dyspnoea and Right Heart Failure
Left Atrial Dilation Pacemaker Damage AF
Left Atrial Dilation Oesophageal Compression Dysphagia
Left Atrial Dilation Bronchial Vein Rupture Haemoptysis
Risk Factors:
Rheumatic Fever
Old Age – Calcification
Differentials:
Atrial Myoxoma - Benign tumour in the left atrium that blocks valve (seen on ultrasound). Will have weight loss and systemic signs
Examination:
End of the bed - Signs of heart failure e.g Peripheral oedema
Hands - Pulse (May be in AF)
Neck - Raised JVP
Face - Malar Flush
Chest:
Rumbling mid diastolic murmur
Best heard with bell of stethoscope in apex when patient lying on left side
“Lub de Derrrr
Loud S1 sound - High LA pressure keeps valve open till later and then slams shut
Opening snap - High pitched sound after S2
Left parasternal heave - RVH
Tapping apex beat due to palpable S1
What are the causes and what will you find on history/examination of Mitral regurgitation?
Symptoms:
Heart Failure
Commonly present as AF
Haemoptysis (bronchial vein rupture due to raised Left atrial pressure)
Risk Factors:
Rheumatic Fever
Old Age - Calcification
Cardiac History Questions to ask: Chest pain Shortness of breath (exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea) Cough - Sputum/Haemoptysis Palpitations - Tap out the rhythm Oedema Syncope Cardiovascular history- Stroke, PVD, smoking, high cholesterol, high blood pressure, diabetes, family history of early cardiac death.
Differentials to rule out:
Atrial Myoxoma - Benign tumour in the left atrium that blocks valve (seen on ultrasound). Will have weight loss and systemic signs
What will you find/look for on examination of a patient with Aortic regurgitation?
Causes: Rheumatic fever Bicuspid valve Infective Endocarditis Connective Tissue Disorders Syphilis
Symptoms:
Asymptomatic
Left heart failure
Risk Factors: Rheumatic fever Bicuspid valve Infective Endocarditis Connective Tissue Disorders Syphilis
Examination:
Hand:
Collapsing Pulse
Wide Pulse Pressure
Quinckes Sign - Capillary pulsation in mail bed
Face - De Musset’s sign (Head nodding with each heartbeat)
Chest:
High pitched early diastolic murmur
Best heard left sternal edge, 4th intercostal space with patient leaning forward in expiration
“Lub Taarrrr”
Displaced Apex beat
Legs - Pistol shot femoral pulses (Sharp bang on auscultation of femorals with each heartbeat)
What will you find/look for on examination of a patient with Aortic stenosis?
Causes:
Under 65 - Bicuspid Aortic Valve
Over 65 - Age Related Calcification
Rheumatic Fever
Symptoms:
Classic Triad of Angina, Syncope and Dyspnoea on exertion caused by impaired blood flow to brain/heart
Sudden cardiac death
Risk Factors:
Under 65 - Bicuspid Aortic Valve
Over 65 - Age Related Calcification
Rheumatic Fever
Differentials:
Angina
Examination: Hands Slow rising pulse Low volume pulse Narrow pulse pressure Chest: Ejection systolic murmur radiating to the carotids "Lub Whooosh Dub" Forceful apex beat Soft S2 heart sound
What investigations will you order in Valve disease?
Bedside:
ECG
Mitral Regurgitation - Bifid P waves, LVH (S wave in V1 + R wave in V5/6 > 3.5 large squares)
Mitral stenosis – Atrial Fibrillation, Bifid P wave, RVH (right axis deviation, tall R waves in V1/2)
Aortic regurgitation - LVH
Aortic stenosis - LVH, left ventricular strain (depressed ST and inverted T waves in LV leads)
Bloods:
BNP - Rule out heart failure
FBC - Look for anaemia
U&E/LFT - Giving drugs like ace inhibitors
Imaging:
CXR - Mitral Regurgitation (Heart Failure), Mitral stenosis (Large left atrium and Pulmonary oedema), Aortic Stenosis (Small heart with dilated ascending aorta)
Echo - Diagnostic test
What is the treatment of valve disease?
Medical:
Diuretics and Nitrates for symptom management until surgery
If not for surgical management then treat as heart failure (Ace inhibitor, Beta Blocker, Spironolactone)
Surgical:
Asymptomatic - Yearly review of patients with known valvular disease
Symptomatic – Valve replacement
What are the complications of valve disease?
Heart Failure on affected side Sudden cardiac death (aortic stenosis) Arrhythmia's Stroke/Clots Infective endocarditis
What are the complications of Prosthetic heart valves?
Structural valve failure Paravulvular leak Thrombosis and obstruction Infective endocarditis Intravascular haemolysis Complications relating to warfarin they need to take
General Rules for Murmurs
General Rules of Valve Lesions:
Left sided murmurs - Best on expiration
Right sided murmurs - Best on inspiration
Regurgitation - Displaced Apex
Stenosis – Change in apex but no displacement
Summary of murmurs:
Ejection systolic - aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan systolic - Mitral/Tricuspid regurgitation (high-pitched and ‘blowing’ in character), VSD (‘harsh’ in character)
Late systolic - mitral valve prolapse, coarctation of aorta
Early diastolic -aortic regurgitation (high-pitched and ‘blowing’ in character), Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)
Mid-late diastolic - mitral stenosis (‘rumbling’ in character), Austin-Flint murmur (severe aortic regurgitation, again is ‘rumbling’ in character)
Continuous machine-like murmur -patent ductus arteriosus
